This week Baroness Amos published the final report of the Independent National Maternity and Neonatal Investigation.
Recognising the contribution of families and staff
We are grateful to everyone who shared their experiences to inform this work. GBSS contributed to the investigation and facilitated an online discussion between families affected by group B Strep and a member of the investigation team, helping to ensure that families’ experiences were heard.
Many families will recognise themes that have appeared in previous reviews and investigations and may feel both sadness and frustration that change has not happened more quickly.
We recognise the many healthcare professionals who are committed to providing safe, compassionate care and who are often working in challenging circumstances. Improving care depends not only on learning from families’ experiences, but also on ensuring staff have the support, resources and working environments they need.
Key points from the report
The report concludes that maternity and neonatal services in England require urgent reform. Among its key findings are that:
- Women, birthing people and families are not always listened to when they raise concerns about their own or their baby’s health. This can have serious consequences for safety, experience and trust.
- Racism, discrimination and inequalities continue to affect both care and outcomes, meaning that not everyone receives equitable, respectful and compassionate care.
- There is too much variation in maternity and neonatal care across England.
- Staff are working under considerable pressure, but repeated recommendations have not yet led to the sustained improvements that families and staff need.
The report makes eight headline recommendations, including stronger national leadership and accountability, improved maternity triage, better support when things go wrong, action to tackle inequalities, and clearer national standards for maternity and neonatal care.
What Baroness Amos is calling for
The report sets out eight major recommendations and also identifies actions that can begin now. These include:
- Improving maternity triage and ensuring concerns are listened to and acted on promptly.
- Better support for women, birthing people, families and staff when things go wrong.
- Tackling racism, discrimination and inequalities as a patient safety priority.
- Creating clearer national standards and reducing variation in care.
- Strengthening accountability, leadership and oversight across the maternity and neonatal system.
- Ensuring the voices of women, birthing people and families are embedded in the design, delivery and improvement of services.
The report also recommends creating a national Maternity and Neonatal Commissioner to help drive change and ensure progress is sustained.
The view from GBSS
For GBSS, the emphasis on listening to concerns, supporting informed-decision making, reducing inequalities and reducing variation in care is especially important. For families affected by group B Strep infection, these themes are particularly important. Recognising the signs of infection, responding appropriately to concerns, providing consistent information and reducing variation in care can all play an important role in preventing avoidable harm. Clear national standards, timely access to information and consistent implementation can help prevent avoidable infections and save babies’ lives.
Jane Plumb, Chief Executive of Group B Strep Support, said:
“Many families affected by group B Strep contributed to this investigation because they want a safer future for others. We know how difficult it can be to revisit experiences of harm, loss and trauma and we’re grateful to everyone who shared their experience.”
“Many families will read this report and feel both validated and frustrated: validated because their experiences have been recognised; frustrated because so many of these issues have been raised before.”
“One of the report’s strongest messages is that listening to women, birthing people and families is a patient safety issue. People need to be heard when they raise concerns, supported to make informed choices and treated as partners in their care. Everyone should be able to expect safe, compassionate and equitable care, regardless of their background, circumstance or postcode.”
“The focus on responsive care, informed choice, equity and reducing variation is particularly important. These are all areas that can help prevent avoidable infections and improve outcomes for babies and families.”
Looking ahead
The challenge now is not identifying what needs to change, but making change happen.
Families and healthcare professionals have heard many similar recommendations over recent years. Success will be measured not by the publication of another report, but by whether its recommendations are implemented and lead to tangible improvements in care and outcomes.
We owe it to everyone affected by harm, everyone who has shared their experiences and everyone working to provide safe care to ensure that this report leads to meaningful and lasting change.
GBSS will continue working alongside families, healthcare professionals, policymakers and partner organisations to help make maternity and newborn care safer for all.
